Esthetic considerations in implant placement Esthetic considerations in implant placementEsthetic considerations in implant placementEsthetic considerations in implant placementEsthetic considerations in implant placementEsthetic considerations in implant placementEsthetic considerations in implant placementEsthetic considerations in implant placementEsthetic considerations in implant placement

1. ESTHETIC CONSIDERATIONSESTHETIC CONSIDERATIONS
IN DENTAL IMPLANTIN DENTAL IMPLANT
Under the guidance of:
Dr. Arun Kumar Gupta(Prof.
&Head)
Dr. Jyoti Paliwal(Prof.)
Dr. Sumit Bhansali(Asso.Prof.)
Presented by:
Dr.
Ravinder(PG-2nd
yrs)

2. CONTENTSCONTENTS
 DEFINITIONDEFINITION
 INTRODUCTIONINTRODUCTION
 ESTHETIC CONSIDRATIONESTHETIC CONSIDRATION
 TREATMENT PLANINGTREATMENT PLANING

3. Esthetics from the GreekEsthetics from the Greek
aisthesis (perception)aisthesis (perception)
Is the theory of experienced –Is the theory of experienced –
based judgement by which anbased judgement by which an
optical stimulus is not simplyoptical stimulus is not simply
perceived as an object ofperceived as an object of
conciousness but evaluated asconciousness but evaluated as
pleasant or un pleasant ,beautifulpleasant or un pleasant ,beautiful
or ugly.or ugly.

5.  It is the philosophy ,psychology and sociology ofIt is the philosophy ,psychology and sociology of
the beautiful in art and nature.the beautiful in art and nature.
 In DentistryIn Dentistry,, EstheticsEsthetics can be defined as thecan be defined as the
theory and philosophy that deals with beauty andtheory and philosophy that deals with beauty and
beautiful especially with respect to the appearancebeautiful especially with respect to the appearance
of a dental restoration as achieved through itsof a dental restoration as achieved through its
form and or colour.form and or colour.

6. IntroductionIntroduction
To achieve a successful esthetic resultTo achieve a successful esthetic result
and good patient satisfaction, implantand good patient satisfaction, implant
placement in the esthetic zoneplacement in the esthetic zone
demands a thorough understanding ofdemands a thorough understanding of
 AnatomicAnatomic
 BiologicBiologic
 SurgicalSurgical
 Prosthetic principlesProsthetic principles..

7. Guidelines are presented for idealGuidelines are presented for ideal
implant positioning and for a variety ofimplant positioning and for a variety of
therapeutic modalities that can betherapeutic modalities that can be
implemented for addressing differentimplemented for addressing different
clinical situations involving replacementclinical situations involving replacement
of missing teeth in the esthetic zoneof missing teeth in the esthetic zone..

8. DIAGNOSIS AND TREATMENTDIAGNOSIS AND TREATMENT
To achieve a successful esthetic result, implantTo achieve a successful esthetic result, implant
placement in the esthetic zone demandsplacement in the esthetic zone demands
thorough pre operative diagnosis and treatmentthorough pre operative diagnosis and treatment
planning combined with excellent clinical skills.planning combined with excellent clinical skills.
Preoperative assessment of the patient’sPreoperative assessment of the patient’s
expectations is also of paramount importance.expectations is also of paramount importance.
If the patient is found to have unrealisticIf the patient is found to have unrealistic
expectations, a careful explanation might beexpectations, a careful explanation might be
necessary to clarify what the patient shouldnecessary to clarify what the patient should
expect.expect.

9. Data collectionData collection
The data base must include the patients chiefThe data base must include the patients chief
complaint, comprehensive medical history,complaint, comprehensive medical history,
dental history, results of extra oral and intra oraldental history, results of extra oral and intra oral
clinical examinations, radiographic examinationclinical examinations, radiographic examination
results, documentation of patient expectations,results, documentation of patient expectations,
and an assessment of risk factors for implantand an assessment of risk factors for implant
failure (esthetic or functional).failure (esthetic or functional).

10. For ideal implant placement and optimal estheticFor ideal implant placement and optimal esthetic
restorations, a comprehensive evaluation of therestorations, a comprehensive evaluation of the
edentulous site must be performed. Facial, dental,edentulous site must be performed. Facial, dental,
and periodontal status must be evaluated.and periodontal status must be evaluated.
A facial evaluation provides general estheticA facial evaluation provides general esthetic
parameters, such as orientation of occlusal plane,parameters, such as orientation of occlusal plane,
lip support, symmetry, gingival scaffold, and smilelip support, symmetry, gingival scaffold, and smile
lineline

11. Esthetic ConsiderationsEsthetic Considerations
The Course of the alveolar ridgeThe Course of the alveolar ridge
The course and state of the health ofThe course and state of the health of
mucosamucosa
The crown marginThe crown margin
The crown formThe crown form
The inter dental spacesThe inter dental spaces
Lip supportLip support
Smile lineSmile line

12. Alveolar ridgeAlveolar ridge
 Adequate widthAdequate width
 well rounded.well rounded.
Status of mucosaStatus of mucosa
 Loss of architectureLoss of architecture
of gingiva and its papillaof gingiva and its papilla
due to loss of tooth-due to loss of tooth-
Diminishes appearance.Diminishes appearance.

13. Gingival recession andGingival recession and
biotypesbiotypes
The gingival biotype should be assessed becauseThe gingival biotype should be assessed because
such an assessment will partly determine the risk forsuch an assessment will partly determine the risk for
post surgical recession.post surgical recession.
A thin, highly scalloped gingival biotype is much lessA thin, highly scalloped gingival biotype is much less
resistant to trauma from surgical or restorativeresistant to trauma from surgical or restorative
procedures and, consequently, is more prone toprocedures and, consequently, is more prone to
recession in comparison with a thick, flat gingivalrecession in comparison with a thick, flat gingival
biotype.biotype.

15. A thin gingival biotype dictates placement of theA thin gingival biotype dictates placement of the
implant in a slightly more palatal position toimplant in a slightly more palatal position to
reduce the chance of recession and prevent areduce the chance of recession and prevent a
titanium “shadow” from showing through the thintitanium “shadow” from showing through the thin
gingival tissue.gingival tissue.
Similarly, the implant should be placed somewhatSimilarly, the implant should be placed somewhat
more apically to achieve a proper emergencemore apically to achieve a proper emergence
profile and avoid a ridge lap restorations.profile and avoid a ridge lap restorations.

17. The long term stability of esthetic soft tissueThe long term stability of esthetic soft tissue
around an implant restorations depends largely onaround an implant restorations depends largely on
the presence of adequate soft tissue volume in athe presence of adequate soft tissue volume in a
vertical and buccolingual direction.vertical and buccolingual direction.
An adequate volume of soft tissue provides a goodAn adequate volume of soft tissue provides a good
emergence profile of the implant restoration andemergence profile of the implant restoration and
serves to mask the underlying metal implant, A subserves to mask the underlying metal implant, A sub
epithelial connective tissue graft may beepithelial connective tissue graft may be
considered to augment soft tissue volume whenconsidered to augment soft tissue volume when
insufficient tissue volume is present.insufficient tissue volume is present.

18. Crown marginCrown margin
 Fabrication Of supra structureFabrication Of supra structure
for implants to be symmetricalfor implants to be symmetrical
to the adjacent teeth.to the adjacent teeth.
Crown FormCrown Form
 Selection of proper implantSelection of proper implant
diameter helps in design ofdiameter helps in design of
single missing natural toothsingle missing natural tooth..

19. Inter dental spacesInter dental spaces
Successful placement of the implant atSuccessful placement of the implant at
the site at Which the crown unit is to bethe site at Which the crown unit is to be
built up is the prerequisite for correctbuilt up is the prerequisite for correct
formation of inter dental spaces.formation of inter dental spaces.

20. The supporting bone influences the establishmentThe supporting bone influences the establishment
of overlying soft tissue compartments and theof overlying soft tissue compartments and the
bone quality and quantity must be carefullybone quality and quantity must be carefully
assessed.assessed.
The vertical bone height in the inter proximal sites,The vertical bone height in the inter proximal sites,
as well as the horizontal thickness and verticalas well as the horizontal thickness and vertical
height of the buccal bone wall in the edentulousheight of the buccal bone wall in the edentulous
site, are important determinants of estheticsite, are important determinants of esthetic
success.success.
The bone crest should be within a physiologicalThe bone crest should be within a physiological
distance of 2 to 3 mm of the cemento-enameldistance of 2 to 3 mm of the cemento-enamel
junction or, when recession is present, 2 to 3 mmjunction or, when recession is present, 2 to 3 mm
of the buccal gingival margin.of the buccal gingival margin.

21. The distance between the underlying interproximalThe distance between the underlying interproximal
bone height on the adjacent natural teeth and thebone height on the adjacent natural teeth and the
final prosthetic contact point dictates the formationfinal prosthetic contact point dictates the formation
and spontaneous regeneration of the inter dentaland spontaneous regeneration of the inter dental
papillae associated with the implant .papillae associated with the implant .
If this distance is more than 5 mm, the completeIf this distance is more than 5 mm, the complete
papilla formation will be compromised.papilla formation will be compromised.
This often leads to the so called “blank triangle”.This often leads to the so called “blank triangle”.
This effect may differ according to whether theThis effect may differ according to whether the
implants is adjacent to another implant or a naturalimplants is adjacent to another implant or a natural
tooth.tooth.

22. Tarnow ,etal in 2003Tarnow ,etal in 2003
Investigated the clinical problem of theInvestigated the clinical problem of the
difficulty of maintaining or reforming adifficulty of maintaining or reforming a
papilla between two implantspapilla between two implants
One reason for this difficulty is that theOne reason for this difficulty is that the
biological width around an implant isbiological width around an implant is
apical to the implant abutment connectionapical to the implant abutment connection

23. Lip SupportLip Support
The lost tissue must be built into theThe lost tissue must be built into the
reconstruction in such a way that lipreconstruction in such a way that lip
support,profile , function, esthetics andsupport,profile , function, esthetics and
phonetics are reproduced while placingphonetics are reproduced while placing
the implants.the implants.

24. Resting lip
position
RELAXED
SMILE
FULLY
ANIMATED
SMILE

25. Smile LineSmile Line
o It is a decisive factorIt is a decisive factor
in the evaluation of thein the evaluation of the
patients estheticspatients esthetics
requirements .requirements .
o The lower margin ofThe lower margin of
the upper lip alsothe upper lip also
called the smile linecalled the smile line
,serves as an,serves as an
orientation guide fororientation guide for
the limits of visibility ofthe limits of visibility of
the teeth.the teeth.

28.  Three possible esthetic situations may ariseThree possible esthetic situations may arise
according toaccording to REITHERREITHER
 Incisal EffectIncisal Effect
 Cervical EffectCervical Effect
 Gingival EffectGingival Effect

29. Four main factors directly affect theFour main factors directly affect the
esthetic outcome of implant supportedesthetic outcome of implant supported
restorations:restorations:
 implant placementimplant placement
 soft tissue managementsoft tissue management
 bone grafting considerationsbone grafting considerations
 prosthetic considerations.prosthetic considerations.
TREATMENT CONSIDERATIONSTREATMENT CONSIDERATIONS

30. Implant PlacementImplant Placement
Implant placement is divided intoImplant placement is divided into
two aspects:two aspects:
 positioningpositioning
 implant sizing.implant sizing.

31. PositioningPositioning
Positioning of an implant is the first step inPositioning of an implant is the first step in
gaining prime esthetic results. Fabricationgaining prime esthetic results. Fabrication
of the proper surgical guide (template) isof the proper surgical guide (template) is
the key to such an achievement.the key to such an achievement.
Positioning involves three planes;Positioning involves three planes;
 apico-occlusal,apico-occlusal,
 mesio-distal,mesio-distal,
 labio-palatal planes.labio-palatal planes.

32. Positioning of implants-Positioning of implants-
esthetic criteriaesthetic criteria
Buccolingual positioning of implantsBuccolingual positioning of implants
Vertical positioning of implantsVertical positioning of implants

33. Apico-occlusal positioningApico-occlusal positioning..
Apico-occlusal positioning of the implant in anApico-occlusal positioning of the implant in an
axial direction must be 2 to 3 mm above anaxial direction must be 2 to 3 mm above an
imaginary line connecting the cementoenamelimaginary line connecting the cementoenamel
teeth.teeth.
Less than 2 mm will lead to a short crown (whichLess than 2 mm will lead to a short crown (which
is impossible to correct), and more than 3 mmis impossible to correct), and more than 3 mm
will hinder proper hygienic maintenance becausewill hinder proper hygienic maintenance because
of increased pocket depth around theof increased pocket depth around the
transmucosal insert.transmucosal insert.
Placing the implant 3 mm below is mandatory toPlacing the implant 3 mm below is mandatory to
allow transfer in cross section from the implantallow transfer in cross section from the implant
head diameter to the natural tooth diameter athead diameter to the natural tooth diameter at
the point of emergence from the gingival crest.the point of emergence from the gingival crest.

34. Placing the implant too far palatally will result in aPlacing the implant too far palatally will result in a
“ditched in “ restoration. This is over come by“ditched in “ restoration. This is over come by
using a modified ridge lap design for the finalusing a modified ridge lap design for the final
restoration, which is unfavorable from hygienicrestoration, which is unfavorable from hygienic
and esthetic points of view; it may also createand esthetic points of view; it may also create
increased strain on the implant when loaded.increased strain on the implant when loaded.
Placing the implant too far labially will result in anPlacing the implant too far labially will result in an
esthetically bulky crown that is impossible toesthetically bulky crown that is impossible to
correct, even with the use of angulated abutments.correct, even with the use of angulated abutments.
Labiopalatal positioningLabiopalatal positioning..

35. In screw retained anterior restorations, theIn screw retained anterior restorations, the
implant is generally placed slightly lingualimplant is generally placed slightly lingual
or palatal to the long axis of the crown.or palatal to the long axis of the crown.
In all cemented restorations and posteriorIn all cemented restorations and posterior
screw retained restorations, the implantscrew retained restorations, the implant
should be located exactly in the center ofshould be located exactly in the center of
the long axis of the crown.the long axis of the crown.

36. Mesiodistal positioning.Mesiodistal positioning.
Through case design andThrough case design and
preoperative planning,preoperative planning,
an implant positioningan implant positioning
in a mesio-distalin a mesio-distal
dimension that has adimension that has a
proper relationshipproper relationship
between the teeth can bebetween the teeth can be
achievedachieved

37. ..
The middle orientation in a mesio-distalThe middle orientation in a mesio-distal
direction is mandatory to avoid placingdirection is mandatory to avoid placing
the implant in the inter dental papillarythe implant in the inter dental papillary
position and subsequent approximationposition and subsequent approximation
of the neighboring roots.of the neighboring roots.
Mesio distal dimension of the tooth rootMesio distal dimension of the tooth root
which determines the size of thewhich determines the size of the
appropriate implant.appropriate implant.

38. TOOTH ROOT AS ATOOTH ROOT AS A
DETERMINANT FORDETERMINANT FOR
OPTIMAL IMPLANTOPTIMAL IMPLANT
SIZE:SIZE:
 In young individuals-attachmentIn young individuals-attachment
mechanism for natural tooth ismechanism for natural tooth is
near CEJ.near CEJ.
 With age-recession is seenWith age-recession is seen
 Thus, it has been concludedThus, it has been concluded
that CEJ minus 2mm is a goodthat CEJ minus 2mm is a good
location to assess the averagelocation to assess the average
size of a tooth root to determinesize of a tooth root to determine
the optimal implant size forthe optimal implant size for
replacing the tooth.replacing the tooth.

39. MesiodistMesiodist
alal
CrownCrown
MesiodistMesiodist
al CEJal CEJ
(mm)(mm)
MesiodistMesiodist
al CEJ –al CEJ –
2mm2mm
RecommendRecommend
ed implanted implant
CENTRALCENTRAL 8.68.6 6.46.4 5.55.5 4.1,4.1,
4.3,5.04.3,5.0
LATERALLATERAL 6.66.6 4.74.7 4.34.3 3.25,3.5,3.25,3.5,
4.1,4.34.1,4.3
CANINECANINE 7.67.6 5.65.6 4.64.6 4.1,4.34.1,4.3
I PREMOLARI PREMOLAR 7.17.1 4.84.8 4.24.2 4.1,4.34.1,4.3
MESIODISTAL CROWN AND ROOTMESIODISTAL CROWN AND ROOT
DIAMETER OF MAXILLARY TEETH ANDDIAMETER OF MAXILLARY TEETH AND
IMPLANT RECOMMENDATIONSIMPLANT RECOMMENDATIONS

40. Implant sizingImplant sizing
Selecting an implant diameterSelecting an implant diameter
that almost matches that ofthat almost matches that of
the natural tooth at thethe natural tooth at the
cervical area will improve thecervical area will improve the
esthetic outcome.esthetic outcome.
Failure to use the properFailure to use the proper
implant size must beimplant size must be
compensated for by sinkingcompensated for by sinking
the implant 3 mm below thethe implant 3 mm below the
CEJ of the neighboring teeth.CEJ of the neighboring teeth.

41. CERAMIC IMPLANTCERAMIC IMPLANT
 The PURE Ceramic Implant offers you a uniqueThe PURE Ceramic Implant offers you a unique
esthetic solution to treat patients with specificesthetic solution to treat patients with specific
needs. While some patients have a thin gingivaneeds. While some patients have a thin gingiva
biotype, which requires a specific treatmentbiotype, which requires a specific treatment
approach, other patients express their explicit wishapproach, other patients express their explicit wish
for a metal-free alternative.for a metal-free alternative.
 High predictability with revolutionary osseointegrationHigh predictability with revolutionary osseointegration
features equivalent to the established SLA® surfacefeatures equivalent to the established SLA® surface2,3,42,3,4
 100 % proof test ensuring reliable implant strength100 % proof test ensuring reliable implant strength
 High end esthetic solution thanks to ivory-coloredHigh end esthetic solution thanks to ivory-colored
materialmaterial

43. Soft tissue managementSoft tissue management
Delicate handling of the soft tissue is considered toDelicate handling of the soft tissue is considered to
be the main factor in gaining a pleasant estheticbe the main factor in gaining a pleasant esthetic
out come.out come.
Soft tissue management includes handling of theSoft tissue management includes handling of the
soft tissue at the time of implant placement,soft tissue at the time of implant placement,
abutment connection, and soft tissue grafting (ifabutment connection, and soft tissue grafting (if
needed). Soft tissue management should beneeded). Soft tissue management should be
considered in the following treatment steps.considered in the following treatment steps.

44. Mucoperiosteal flapMucoperiosteal flap ::
The horizontal incision should be made along a lineThe horizontal incision should be made along a line
connecting the palatal line angles of the adjacentconnecting the palatal line angles of the adjacent
teeth, and the vertical incision should be made at theteeth, and the vertical incision should be made at the
adjacent teeth (ie, a normal marginal incision shouldadjacent teeth (ie, a normal marginal incision should
be made with complete mobilization of the interbe made with complete mobilization of the inter
dental papillae).dental papillae).
The incision should allow optimal mobilization of theThe incision should allow optimal mobilization of the
mucoperiosteal flap. A preservative inter dentalmucoperiosteal flap. A preservative inter dental
papillae incision is advantageous because it helps topapillae incision is advantageous because it helps to
prevent dropping of the mucoperiosteal flap withprevent dropping of the mucoperiosteal flap with
subsequent shrinkage (partial marginal section).subsequent shrinkage (partial marginal section).

45. Preservation of the interdental papillaePreservation of the interdental papillae

46. Second stage surgery.Second stage surgery.
At this stage, the gingival margin around theAt this stage, the gingival margin around the
implant can be corrected or improved to a greatimplant can be corrected or improved to a great
extent.extent.
Bulking the keratinized tissue labially aroundBulking the keratinized tissue labially around
the healing heads is one technique used tothe healing heads is one technique used to
enhance the esthetic outcome. A modifiedenhance the esthetic outcome. A modified
palatal roll flap is commonly used to bulk uppalatal roll flap is commonly used to bulk up
tissue labially.tissue labially.
Soft tissue management at abutmentSoft tissue management at abutment
connection.connection.

47. Lack of soft tissueLack of soft tissue
bulking over the labialbulking over the labial
plateplate
Bulking up of theBulking up of the
keratinized tissuekeratinized tissue
labially during secondlabially during second
stage surgerystage surgery

48. Gingival grafting.Gingival grafting.
Soft tissue deficiencies can be corrected at thisSoft tissue deficiencies can be corrected at this
stage of treatment (eg. A lack of keratinizedstage of treatment (eg. A lack of keratinized
tissue would be corrected by means of freetissue would be corrected by means of free
gingival grafting or sliding flaps) .gingival grafting or sliding flaps) .
Small tissue dimples or labiocrestal concavitiesSmall tissue dimples or labiocrestal concavities
can be corrected by sub epithelial connectivecan be corrected by sub epithelial connective
tissue grafting to bulk up the tissue labially iftissue grafting to bulk up the tissue labially if
needed (note the soft tissue drop andneeded (note the soft tissue drop and
mishandling). Also, gingivoplasty, using amishandling). Also, gingivoplasty, using a
diamond bur, is used to correct flat or ledgeddiamond bur, is used to correct flat or ledged
margins.margins.

49. Soft tissue drop due to improper design ofSoft tissue drop due to improper design of
the incisionthe incision

50.  Papillary illusion, by allowing a substantialPapillary illusion, by allowing a substantial
excess of keratinized tissues to be stabilized atexcess of keratinized tissues to be stabilized at
the implant site, can also be created.the implant site, can also be created.
 Preservation of the papillae is the mostPreservation of the papillae is the most
important factor in creating a natural lookingimportant factor in creating a natural looking
implant supported restorations. Papillae can beimplant supported restorations. Papillae can be
created surgically by using several techniques.created surgically by using several techniques.

51.  Coronally repositioned flapCoronally repositioned flap
 A C-shaped incision is made at the implant siteA C-shaped incision is made at the implant site
with the convexity toward the labial surface.with the convexity toward the labial surface.
The circumference of the incision should beThe circumference of the incision should be
deeper than that of the abutment.deeper than that of the abutment.
 Thus, when the flap is repositioned coronally,Thus, when the flap is repositioned coronally,
excess tissue will be present between theexcess tissue will be present between the
abutment and the adjacent teeth. This excessabutment and the adjacent teeth. This excess
tissue will createtissue will create a papillary illusiona papillary illusion. The. The
disadvantages of this technique is a reduction indisadvantages of this technique is a reduction in
labio-attached gingiva.labio-attached gingiva.

52. Lateral compression of the gingivaLateral compression of the gingiva..
An incision is made over the cover screw (afterAn incision is made over the cover screw (after
it is carefully localized using a probe). Theit is carefully localized using a probe). The
incision should imitate an extraction wound soincision should imitate an extraction wound so
that the cover screw will be partly covered bythat the cover screw will be partly covered by
tissue after the incision.tissue after the incision.
This tissue should be compressed beforeThis tissue should be compressed before
removal of the cover screw. After abutmentremoval of the cover screw. After abutment
connection, the surrounding tissue will beconnection, the surrounding tissue will be
compressed and raised to create natural lookingcompressed and raised to create natural looking
papillae.papillae.

53. Gingival recontouringGingival recontouring
Several clinician technique have been proposedSeveral clinician technique have been proposed
for reshaping the gingival profile, provided that afor reshaping the gingival profile, provided that a
sufficient volume of soft tissue is present.sufficient volume of soft tissue is present.
Wide, temporary healing abutment are used toWide, temporary healing abutment are used to
allow gingival maturation around a wide cap.allow gingival maturation around a wide cap.
Gingival electro-surgery is used to cut theGingival electro-surgery is used to cut the
desired gingival contour.desired gingival contour.

54. Bone Grafting ConsiderationsBone Grafting Considerations
Does the final restorationsDoes the final restorations
determine the implant site, ordetermine the implant site, or
does bone availabilitydoes bone availability
determine the implant sitedetermine the implant site??

55. Prosthetically driven
implant placement
Amount of bone
formed after guided
tissue regeneration

56. Restoration driven implant placement is theRestoration driven implant placement is the
ultimate goal regardless of the amount ofultimate goal regardless of the amount of
available bone.available bone.
Bone grafting procedures (autogenous,Bone grafting procedures (autogenous,
allogenous, or synthetic ) have given theallogenous, or synthetic ) have given the
clinician a wide range of treatment modalitiesclinician a wide range of treatment modalities
(note the proper positioning of the implant(note the proper positioning of the implant
despite the lack of labial bone and thedespite the lack of labial bone and the
achievement of a good bulk of bone by meansachievement of a good bulk of bone by means
of current grafting techniques.of current grafting techniques.

57. Prosthetic ConsiderationsProsthetic Considerations –– EstheticEsthetic
ImplantImplant
 EVALUATION of prospective implant site shouldEVALUATION of prospective implant site should
arise primarily from prosthetic point of view.arise primarily from prosthetic point of view.
 The time long past when implants were insertedThe time long past when implants were inserted
correctly from surgeons point of view but turnedcorrectly from surgeons point of view but turned
to be unusable prosthetically.to be unusable prosthetically.
 This principle is doubly important for estheticallyThis principle is doubly important for esthetically
demanding situations.demanding situations.

58. Implant must be understood as an extension ofImplant must be understood as an extension of
the optimally located super structure.the optimally located super structure.
GARBER and BELSER have described thisGARBER and BELSER have described this
constraint as RESTORATION-DRIVEN IMPLANTconstraint as RESTORATION-DRIVEN IMPLANT
PLACEMENT AND RESTORATION-DRIVEN SITEPLACEMENT AND RESTORATION-DRIVEN SITE
DEVELOPMENTDEVELOPMENT

59. Soft tissue profile or prosthetic recipient site fromSoft tissue profile or prosthetic recipient site from
which the restoration emerges should bewhich the restoration emerges should be
identical to that around the contralateral tooth isidentical to that around the contralateral tooth is
the basis for all the esthetic restorations.the basis for all the esthetic restorations.
Numerous restorative materials, technologies,Numerous restorative materials, technologies,
and clinical procedures have been developed.and clinical procedures have been developed.
for example – tooth colored abutments,for example – tooth colored abutments,
anatomical abutments, tapered but wideanatomical abutments, tapered but wide
healing heads.healing heads.

60. Cervical contour-Cervical contour-
Cervical contouring is one factorCervical contouring is one factor
responsible for the proper configuration ofresponsible for the proper configuration of
the peri implant soft tissues. It alsothe peri implant soft tissues. It also
corrects the discrepancies between thecorrects the discrepancies between the
diameter of the implant body and that ofdiameter of the implant body and that of
the natural teeth.the natural teeth.

61. This ideal design is transferred to vital oralThis ideal design is transferred to vital oral
tissue through the abutment and the provisionaltissue through the abutment and the provisional
restorations, which are fabricated to guide therestorations, which are fabricated to guide the
soft tissue to initiate the replica model.soft tissue to initiate the replica model.
Cervical contouring also focuses on shaping theCervical contouring also focuses on shaping the
abutment and the cervical crown regionabutment and the cervical crown region
following the previous design of the surroundingfollowing the previous design of the surrounding
tissues.tissues.

62. Anatomical abutments-Anatomical abutments-
Because of the discrepancy in the diameterBecause of the discrepancy in the diameter
between the implant head and the natural toothbetween the implant head and the natural tooth
diameter at the CEJ level the anatomicallydiameter at the CEJ level the anatomically
shaped abutments dramatically improve theshaped abutments dramatically improve the
emergence profile.emergence profile.
Also reduces stress on the connecting screw,Also reduces stress on the connecting screw,
improve mechanical properties, increaseimprove mechanical properties, increase
prosthetic stability, and avoid use of the ridgeprosthetic stability, and avoid use of the ridge
lap design.lap design.

63. Use of traditional narrow abutments will usuallyUse of traditional narrow abutments will usually
lead to an inability to fulfill esthetic goals that it, itlead to an inability to fulfill esthetic goals that it, it
could necessitate a modified ridge lap design,could necessitate a modified ridge lap design,
which is unpleasant esthetically, make hygienicwhich is unpleasant esthetically, make hygienic
procedures difficult, and causes undue stress onprocedures difficult, and causes undue stress on
the implant.the implant.
By using anatomical abutments, the soft tissueBy using anatomical abutments, the soft tissue
will be displaced to create the same diameter aswill be displaced to create the same diameter as
the natural tooth at the CEJ areathe natural tooth at the CEJ area

65. Abutments availableAbutments available
ANGULATED ABUTMENTSANGULATED ABUTMENTS
CERAMIC ABUTMENTS.CERAMIC ABUTMENTS.

66. Abutments with wider cervical marginAbutments with wider cervical margin
 Improves emergence profileImproves emergence profile
 Provides greater surface area forProvides greater surface area for
retention.retention.
 Permits the crown preparation to thePermits the crown preparation to the
needs.needs.

67. Ceramic abutmentsCeramic abutments
are used to enhance the esthetic quality ofare used to enhance the esthetic quality of
implant supported restorations in the anteriorimplant supported restorations in the anterior
maxilla. They are usually used in cases in whichmaxilla. They are usually used in cases in which
the labial soft tissues is thin to allow passage ofthe labial soft tissues is thin to allow passage of
reflective light from a non metallic abutment.reflective light from a non metallic abutment.
Ceramic abutments are fabricated by suingCeramic abutments are fabricated by suing
partially stabilized alumina-Zirconia machinablepartially stabilized alumina-Zirconia machinable
abutments.abutments.

68. After preparation of the abutment, it isAfter preparation of the abutment, it is
glass infiltrated and polished. The finalglass infiltrated and polished. The final
restoration can them be delivered to therestoration can them be delivered to the
patient as an all ceramic crown cementedpatient as an all ceramic crown cemented
over the abutment, or the abutment itselfover the abutment, or the abutment itself
can be procelainized with the abutmentcan be procelainized with the abutment
acting as the final restorations.acting as the final restorations.

69. THE UCLA TYPE ABUTMENTTHE UCLA TYPE ABUTMENT
 The UCLA-Type Abutment is attached directly toThe UCLA-Type Abutment is attached directly to
the implant. It provides a pattern for the creationthe implant. It provides a pattern for the creation
of a screw retained veneered crown.of a screw retained veneered crown.
 UCLA-Type Abutments are available in single-UCLA-Type Abutments are available in single-
implant (hexed) and multi-implant (non-hexed)implant (hexed) and multi-implant (non-hexed)
designs.designs.
 This abutment is well suited forThis abutment is well suited for sites withsites with
minimal thickness of soft tissueminimal thickness of soft tissue. It is available in. It is available in
traditional plasticconfigurations, gold alloy, goldtraditional plasticconfigurations, gold alloy, gold
base with plastic sleeve, and in a titaniumbase with plastic sleeve, and in a titanium
version for provisional restorations.version for provisional restorations.

70. Healing heads-Healing heads-
Wide, temporary healing head are used toWide, temporary healing head are used to
transfer the narrow cross section of the implanttransfer the narrow cross section of the implant
head into the triangular cross section of thehead into the triangular cross section of the
upper anterior teeth by gradually pressingupper anterior teeth by gradually pressing
against the gingival tissue.against the gingival tissue.
This should conform to the nearest cross sectionThis should conform to the nearest cross section
of tooth structure to allow enough room for theof tooth structure to allow enough room for the
anatomical abutments to be placed.anatomical abutments to be placed.

72. TemporizationTemporization
 Temporization is a major clinical step in theTemporization is a major clinical step in the
achievements of a proper esthetic result in anteriorachievements of a proper esthetic result in anterior
tooth restorations . Proper and adequate stimulationtooth restorations . Proper and adequate stimulation
of the gingival tissue must take place becauseof the gingival tissue must take place because
exaggerated pressure could lead to sloughing andexaggerated pressure could lead to sloughing and
necrosis.necrosis.
 After second stage surgery, the tissue must beAfter second stage surgery, the tissue must be
given time to heal and mature to stabilize the gingivalgiven time to heal and mature to stabilize the gingival
margin before the final abutment is selected or finalmargin before the final abutment is selected or final
impressions are made.impressions are made.

73. The provisional restorations allows for soft tissueThe provisional restorations allows for soft tissue
maturation. This usually take 6 to 8 weeks. Thematuration. This usually take 6 to 8 weeks. The
final soft tissue profile should be replicated onfinal soft tissue profile should be replicated on
the model, so the provisional restorations shouldthe model, so the provisional restorations should
be fabricated according to the desired gingivalbe fabricated according to the desired gingival
contour.contour.
By adding and shaping the acrylic resin on theBy adding and shaping the acrylic resin on the
sub gingival portion of the temporary restoration,sub gingival portion of the temporary restoration,
an esthetic emergence profile and toothan esthetic emergence profile and tooth
dimension can be achieveddimension can be achieved

74. Fabrication of provisionalFabrication of provisional
restorationrestoration
 Impression made at stage I surgery -Impression made at stage I surgery -
Fabrication of provisional restoration.Fabrication of provisional restoration.
 Placement of customized provisionalPlacement of customized provisional
restoration instead of healing abutment.restoration instead of healing abutment.

75. Advantages of placing customAdvantages of placing custom
provisional restorationprovisional restoration
 Exact desired emergence profile can beExact desired emergence profile can be
generated .generated .
 Surgical procedures or soft tissueSurgical procedures or soft tissue
management can be avoided.management can be avoided.
 Acts as a guide to fabricate finalActs as a guide to fabricate final
restoration.restoration.

76. IMPLANT PLACEMENT INIMPLANT PLACEMENT IN
EDENTULOUS SITESEDENTULOUS SITES
When an edentulous site in the esthetic zone isWhen an edentulous site in the esthetic zone is
planned for implant placement, the site must beplanned for implant placement, the site must be
thoroughly evaluated.thoroughly evaluated.
Garber has proposed a classification for suchGarber has proposed a classification for such
sites. This classification depends on the type ofsites. This classification depends on the type of
reconstruction needed to get good positioningreconstruction needed to get good positioning
of the implant.of the implant.

77. Garber Class IGarber Class I
When favorable horizontal and vertical levels ofWhen favorable horizontal and vertical levels of
both soft tissue and bone are present, idealboth soft tissue and bone are present, ideal
implant positioning is a straight forwardimplant positioning is a straight forward
procedure.procedure.
A concomitant soft tissue augmentation at theA concomitant soft tissue augmentation at the
same time of implant placement is preferred insame time of implant placement is preferred in
patients with a thin gingival biotype to preventpatients with a thin gingival biotype to prevent
the risk of soft tissue recession and buccalthe risk of soft tissue recession and buccal
bone resorption.bone resorption.

78. Garber Class IIGarber Class II
Sites with no vertical bone loss and slightSites with no vertical bone loss and slight
horizontal bone deficiency measuring about 1 tohorizontal bone deficiency measuring about 1 to
2 mm narrower than normal can be expanded2 mm narrower than normal can be expanded
by using serial osteotomes instead of drilling.by using serial osteotomes instead of drilling.
This technique will permit slight expansion of theThis technique will permit slight expansion of the
bony ridge horizontally while simultaneouslybony ridge horizontally while simultaneously
compressing the maxillary cancellous bone tocompressing the maxillary cancellous bone to
improve the bone quality.improve the bone quality.

79. Garber Class IIIGarber Class III
For sites with no vertical bone loss andFor sites with no vertical bone loss and
horizontal bone loss greater than Class II,horizontal bone loss greater than Class II,
implant placement can be attempted,implant placement can be attempted,
provided an initial stability is achieved.provided an initial stability is achieved.
Guided bone regeneration is necessary.Guided bone regeneration is necessary.

80. Garber Class IVGarber Class IV
In sites with no vertical bone loss but significantIn sites with no vertical bone loss but significant
horizontal loss, it is necessary to use a stagedhorizontal loss, it is necessary to use a staged
approach in which the ridge is widened withapproach in which the ridge is widened with
guided bone regeneration.guided bone regeneration.
Implants are later placed after a suitableImplants are later placed after a suitable
healing period of several months, using blockhealing period of several months, using block
bone grafts or guided bone regenerationbone grafts or guided bone regeneration
techniques.techniques.

81. Sites with extensive apicocoronal bone lossSites with extensive apicocoronal bone loss
present a significant challenge to the surgeon.present a significant challenge to the surgeon.
As noted above, there are no well documentedAs noted above, there are no well documented
surgical approaches available to predictablysurgical approaches available to predictably
augment bony ridge height.augment bony ridge height.
Some case reports suggest a surgical approachSome case reports suggest a surgical approach
of guided bone regeneration using a nonof guided bone regeneration using a non
restorable membrane and delayed implantrestorable membrane and delayed implant
placement.placement.
Garber Class VGarber Class V

82. REFERENCESREFERENCES
 Soft tissue and Esthetic consideration in implantSoft tissue and Esthetic consideration in implant
therapy: Anthony G Sclartherapy: Anthony G Sclar
 Esthetics in dentistry – vol 1: Ronald eEsthetics in dentistry – vol 1: Ronald e
Goldstein.Goldstein.
 Abd EI Salam EI Askary. Esthetic considerationsAbd EI Salam EI Askary. Esthetic considerations
in anterior single tooth replacement.Implant Dentin anterior single tooth replacement.Implant Dent
1999;8:61-661999;8:61-66
 Avishai sadan, Markus B ,Mike Bellerino,MichaelAvishai sadan, Markus B ,Mike Bellerino,Michael
Block.Prosthetic design considerations forBlock.Prosthetic design considerations for
single-implant restorations. J Esthet Restor Dentsingle-implant restorations. J Esthet Restor Dent
16:165-175,2004.16:165-175,2004.